This may be because, since no instruction is given to delete, it is implicit that the Excludes1: postviral fatigue syndrome (G93.3) remains in place, in accordance with the version of ICD-10-CM for 2011. But if it is implicit that it remains in place, would it not be required to revise the existing draft ICD-10-CM Exclude code from (G93.3) to reflect the code they are proposing should be assigned to CFS?

And in their proposal, they have

Excludes2: chronic fatigue syndrome (G93.32)

but they have chronic fatigue syndrome at G93.33 in their proposal - so I think the IMEA have an inconsistency, there, within the framework of their own proposal. So one of the IMEA Administrators needs to look at that and if it is an inconsistancy, I suggest they revise their proposal before they try to take it forward.

They had proposed

ME G93.31
PVFS G93.32
CFS G93.33

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Yes you are right Suzy, and I agree that that is a mistake/oversight on their part.

They don't say to delete "Excludes1: postviral fatigue syndrome (G93)", so I think I am right to include that, even though the 'G93' reference is now incorrect.

As I've already mentioned, in the draft of ICD-10-CM for 2011, this section of Chapter 5 is arranged differently than in ICD-10 and has Neurasthenia coded at F48.8, not at F48.0, with no specific Exclude that I can see for postviral fatigue syndrome (G93.3).

It should also be noted that for ICD-11 (from pages of the draft not currently displayed in the public version of the draft but archived on my site here)

Postviral fatigue syndrome "Reference G93.3 -> Gj92 Chronic fatigue syndrome" is specified as an Exclusion to Neurasthenia and also specified as an Exclusion to R53 Malaise and fatigue. ("Gj92" was a temporary "Sorting label" assigned to Chronic fatigue syndrome in the early ICD-11 alpha drafting process.)

Oh yes, if my text is correct, then they've both done it.
It should be "Excludes1", shouldn't it, if there's no other "Excludes1" in place preceding it?

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If you look at the PDF of

ICD-10-CM TABULAR LIST of DISEASES and INJURIES 2011

at any chapter, for example, Chapter 18, you will see that Excludes are listed, variously, as

Exclude1 or

Exclude2

irrespective of whether more that one Exclusion term is listed. Sometimes Exclude2 lists only one exclusion term.

So no, I don't think it is the case that a single Exclude would automatically be listed as Exclude1. Also, you will see perhaps eight or ten terms listed against "Exclude1" under some terms.

I think it may refer to a class of Exclude but without doing some research, I cannot clarify under what circumstances "Exclude1" and "Exclude2" are used or why Exclude2 has been used in this specific case.

The word "Includes" appears immediately under certain categories to further define, or give examples of, the content of the category.

Excludes Notes

The ICD-10-CM has two types of excludes notes. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other.

Excludes1

A type 1 Excludes note is a pure excludes. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is for used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2

A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

The word "Includes" appears immediately under certain categories to further define, or give examples of, the content of the category.

Excludes Notes

The ICD-10-CM has two types of excludes notes. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other.

Excludes1

A type 1 Excludes note is a pure excludes. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is for used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2

A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

So, the ICD-10-CM draft as it currently stands has Excludes1 class excludes in both of the relevant sections of Chapter 6 and Chapter 18.

The proposals of the Coalition also have Excludes1.

The suggestion from the NCHS (as reported) has introduced Exclude2 class excludes.

The IMEA have mirrored the NCHS's Exclude2 class excludes.

Question: Does the Coalition and does IMEA understand the difference between Excludes1 and Excludes2 and what might the implications be for Excludes2 class excludes and was it explained at the meeting why Excludes2 class excludes were being suggested?

From the ICD-10-CM document:

"Excludes2

A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together."

If I have time over the weekend, I'll go through the Coalition materials again and listen to the audio to see what, if any, explanation was given by NCHS for the use of Excludes2 class excludes rather than Excludes1, and the rationale for deleting "Chronic fatigue syndrome NOS" from the R code chapter but adding it into Chapter 6 under "Chronic fatigue syndrome".

Again, I ask why on earth would IMEA want "Chronic fatigue syndrome NOS" in the G codes and under what circumstances does it envisage clinicians specifying a Chapter 6 coded "Chronic fatigue syndrome NOS"?

And what is IMEA's rationale for using the Excludes2 class for excludes where the draft as it stands for 2011, uses Excludes1 class excludes?

Thanks, Bob, for putting this information into a form I can understand. Now I can clearly see what all the shouting is about.

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Thanks madie. Glad you found it useful. Actually, it's all down to Suzy's hard work. Suzy provided all of the info, and I wouldn't have had a clue about any of it without her. So it's all Suzy's work really.

Thanks to Suzy and Bob from me, too. That was a lot of work, but it clears up most of the confusion. Marvelous work!

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You're welcome.

I'm pleased we've been able to establish the difference between Excludes1 and Excludes2 classes in ICD-10-CM.

Someone has asked me about the proposed Multisytem Chapter for ICD-11 (ICD-11 is scheduled for pilot implementation in 2015). A Multisystem chapter does not exist in ICD-10 or ICD-10-CM, but has been proposed for ICD-11.

I've posted the following in earlier threads on ICD-11, but there is an ICD-11 Discussion document available from this page on the ICD Revision site:

ICD has traditionally grouped diseases by aetiology and by affected organ system. For ICD11 the creation of a new chapter for multisystem disorders has been proposed. The following text sets out the rationale for and the possible scope of a multisystem disorders chapter.

Contains Literature search reference at 119 to the Maes and Twisk paper, Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a multisystem disease, should target the pathophysiological aberrations (inflammatory and oxidative and nitrosative stress pathways), not the psychosocial barriers for a new equilibrium. 2010: Ireland. p. 148-9.

One of the conditions proposed to be placed under a projected Multisystem Diseases chapter for ICD-11 (currently listed as Chapter 24) is Behet disease.

There is also another ICD-11 Discussion document (which again, I've flagged up in the past, and which is quite interesting) titled, "Signs and Symptoms" which sets out some of the history of the use of the "Signs and Symptoms" chapter and how diseases, conditions and disorders have been moved of this chapter into other chapters.

The Index is an income generator for the WHO and is published only as a copyright print edition or paid for CD Rom. Unlike the Tabular List and Volume 2: The Instruction Manual (which is available in PDF format here), the Index in not available online.

The Introduction to ICD-10 Volume 3: The Alphabetical Index Version for 2006 lists several possible relationships between a term included in the Alphabetical Index and a term included in the Tabular List to which it is indexed:

The terms included in the category of the Tabular List are not exhaustive; they serve as examples of the content of the category or as indicators of its extent and limits. The Index, on the other hand, is intended to include most of the diagnostic terms currently in use. Nevertheless, reference should always be made back to the Tabular List and its notes, as well as the guidelines provided in Volume 2, to ensure that the code given by the Index fits with the information provided by a particular record.

Because of its exhaustive nature, the Index inevitably includes many imprecise and undesirable terms. Since these terms are still occasionally encountered on medical records, coders need an indication of their assignment in the classification, even if this is to a rubric for residual or ill-defined conditions. The presence of a term in this volume, therefore, should not be taken as implying approval of its usage.

and, according to a February 2009 response from WHO HQ Classifications, Terminology and Standards Team, terms that are listed in the Index may be:

a synonym to the label (title) of a category of ICD;

a sub-entity to the disease in the title of a category;

or a best coding guess.​

ICD-10 does not specify whether, in indexing Chronic fatigue syndrome to G93.3, it views the term as a synonym to Postviral fatigue syndrome or to Benign myalgic encephalomyelitis, subclass, sub-entity or other relationship. Nor does ICD-10 specify how it views the relationship between Postviral fatigue syndrome and Benign myalgic encephalomyelitis. (In ICD-11, the relationship between ICD-11 Title categories and their Inclusion terms will be specified. See Terms: Synonyms, Inclusions, ExclusionsiCAT Glossary of ICD-11 Terms)

What has the Classifications, Terminology and Standards Team, WHO, Geneva, said?

I wish to clarify the situation regarding the classification of neurasthenia, fatigue syndrome, post viral fatigue syndrome and benign myalgic encephalomyelitis. Let me state clearly that the World Health Organisation (WHO) has not changed its position on these disorders since the publication of the International Classification of Diseases, 10th Edition in 1992 and versions of it during later years.

Post viral fatigue syndrome remains under the diseases of the nervous system as G93.3. Benign myalgic encephalomyelitis is included within this category. Neurasthenia remains under mental and behavioural disorders as F48.0 and fatigue syndrome is included within this category. However, post viral fatigue syndrome is explicitly excluded from F48.0.

The WHO ICD-10 Diagnostic and Management Guidelines for Mental Disorders in Primary Care, 1996, includes fatigue syndrome under neurasthenia (F48.0) but does not state or imply that conditions belonging to G93.3 should be included here.

I would also like to state that the WHOs position concerning this is reflected in its publications and electronic material, including websites. It is possible that one of the several WHO Collaborating Centres in the United Kingdom presented a view that is at variance with WHOs position. Collaborating Centres are not obliged to seek approval from WHO for the material they publish. I understand that the Collaborating Centre concerned has now made changes to the information on their website after speaking with WHO. Source: ME/CFS: TERMINOLOGY: M Williams, 27 April 2009

2] In a response dated 23 January 2004, Andre lHours, WHO HQ, Geneva, provided the following:

This is to confirm that according to the taxonomic principles governing the Tenth Revision of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems (ICD-10), it is not permitted for the same condition to be classified to more than one rubric as this would mean that the individual categories and subcategories were no longer mutually exclusive.

This confirmation related to a contemporaneous issue concerning the WHO Collaborating Centre, Institute of Psychiatry, but the principle has significance for the DSM-ICD Harmonization issue.

3] In responses from early 2009, Dr Robert Jakob, WHO Classifications, Terminology and Standards Team, reaffirmed that statements made in the past by Dr Saraceno and Mr lHours regarding coding and classification are still valid, adding that:

there is no evidence that any change should be made to this in ICD-11;

the same principles will apply to ICD-11.

Note that none of these responses specifies ICD-10?s view of the relationship between Chronic fatigue syndrome, Postviral fatigue syndrome and Benign myalgic encephalomyelitis.

The ICD-10-CM Tabular List draft version for 2011 is a whopping 7.8 MB PDF and needs extracting from a zipped file; this also includes the PDF for Volume 3: The Alphabetical Index (which is 4.7MB), but I can send these as PDFs on emails, if anyone would like copies. There used to be a page where the latest versions of draft ICD-10-CM could be downloaded as PDFs without the need for unzipping.

The ICD-10-CM document I found yesterday, that contained the definitions for Includes1 and Includes2, also contains a Tabular List, and is a smaller file size (4.7MB). Caveat: for some categories the listings in this document may not be up-to-date with the draft version for 2011 released in late 2010, but the listings for PVFS, (B)ME and CFS NOS do appear the same:

Which has sections on Conventions and structure of the Index and Tabular List.

Also the following on Page 9, on Includes, Inclusion terms and Excludes:

10. Includes Notes
This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

11. Inclusion terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

12. Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.

a. Excludes1
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

b. Excludes2
A type 2 excludes note represents Not included here. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

and on Page 12...

4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms.

I wanted to give a little additional information on each of the options in terms of what was in the proposal, what I presented at the meeting on Sept 14, and the followup discussions since. There are basically 4 options for pointing CFS to G93.3 - 3 are essentially what Bob has listed and the fourth was the counterproposal that I presented at the meeting in response to Option 2. All 4 options were presented and discussed at the IACFSME meeting.

A few points that go across options

Regarding Excludes - it should be Excludes1 for each option. This choice was actually recommended by a participant at the meeting in response to the NCHS proposal to use an Excludes2.

Regarding dropping benign from ME - based on meeting feedback, I think the most that can be done is rename to ME (benign). if this is allowed, it should be done in each option

Regarding changing the heading of G93.3 in option 2,3, and 4 once subcodes are created - need to understand what latitude is allowed here by WHO rules.

Regarding the use of NOS - there may be some coding conventions for that to be used under certain circumstances. See Option 2 where this is mentioned. I need to follow up with NCHS to understand the usage.

Bob - I tried to get Option 3 and the revised option 4 into your nice format but couldnt figure it out so its not very pretty.

I apologize for not providing this information sooner but I am away from home for a month with very limited access to email. Please PM me if you have any questions or if I seem to have misstated something and I will try to respond as soon as I can

Mary Dimmock

Option 1 was the option that the coalition actually proposed. This option is also included in the NCHS materials for the meeting

The Coalition proposal only specified 'Excludes', not 'Excludes1'. The NCHS defined this as 'Excludes1' in their meeting material

Technically, I don't know if an 'Excludes' is required for both PVFS and CFS since CFS points to the PVFS category which has an excludes. If both are required, then presumably an 'excludes' for ME is also required. In the proposal, I specified an excludes for CFS only since the proposal only focused on that term.

​

Option 2 was developed by the NCHS and included in their meeting materials. They proposed this because they have years of data on CFS and PVFS that they do not want to lose by having one code. ME as a code is only rarely used. The intent in this proposal from the PVFS is that the term PVFS be used for those patients with a viral trigger and CFS be used for all other cases. There are three issues with that proposal:

both the ME/CFS Canadian Consensus Criteria and the ME-ICC include viral and bacterial triggers and the ME/CFS CCC explicitly include other triggers like environmental. Splitting out ME-ICC patients with a bacterial trigger and giving them a different diagnosis of CFS would be inappropriate.

Today, U.S. patients who have a known viral trigger have been diagnosed as having CFS

PVFS is an ill-defined term but there is evidence that some think of it as the diagnosis to be given initially, followed by the CFS diagnosis once either more evidence has been acquired or 6 months has passed

​

Two other comments

In developing option 2, NCHS specified the Excludes2 for CFS on the R code. One of the participants in the meeting on Sept 14 stated that she felt the Excludes1 should be used because it wasnt appropriate to have both a G93.3 CFS and a R53.82 CF diagnosis at the same time.

Once PVFS was a subcode, NCHS needed to provide a new title for the category G93.3 which is where 'Postviral and other chonic fatigue syndromes' came from. This is addressed below in option 3.

As above, I dont know whether this has to be an Excludes for each term in category G93.3 or whether the excludes for G93.3 (the overall term) covers it.

Regarding the term CFS NOS under G93.3 I asked why the NOS was used there and believe I understand that it has to do with establishing a default term and because there is no term under the subcode. But I am not clear still and need to follow up on this further. From my perspective, its extraneous and inappropriate to have both a CFS and a CFS, NOS NOS from what?

Addresses the issue of splitting ME-ICC cases with viral triggers from ME-ICC cases with bacterial triggers into two separate names

Counterproposed a different title to G93.3 that what NCHS proposed in Option 2. As Suzy points out, its not clear what latitude there is to change this although the NCHS had already proposed a modification here

I only specified the G93.3 codes in the presentation material with an 'Excludes' for CF. I believe this should be Excludes1 and that there should be Excludes1 on the R codes for G93.3. As stated above, I need to understand whether an Excludes can be provided at the G93.3 level or whether it is needed for each subcode

The counterproposal did not use the term NOS - need to follow up as stated above

The IMEA proposal included a title of Viral and infectious and post-infectious diseases of the nervous system with post-exertion symptoms. I know a number of patients want to get the word Fatigue out of the title and expect that is why this title was proposed. But to Suzys point, I dont know what latitude there is but if it can be changed, it should be changed on option 2,3 and 4

The IMEA proposal also proposed dropping the term Benign from Benign ME. This was discussed at the meeting on Sept 14 and because of WHO rules, it can not be dropped. The audience suggested that it be renamed to ME (Benign). I left the word Benign on all options but if it can be moved to the end, that should happen on every option.

The IMEA proposal has ME first but I believe the discussion at the IACFSME used G93.31 for PVFS and G93.32 for ME.

I am not sure why they included the term CFS NOS but this relates to the issue listed in option 2 above

The Excludes should be an Excludes1. I dont know whether it technically needs to be listed for each term or for the category. Whatever decision is made, this should also be the same for all options.